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Thursday, January 19, 2006

Legislators challenge Tenncare managed care rules

Tenncare, a health care reform program, essentially replaced the Medicaid program in Tennessee. TennCare was designed as a managed care model. It extended coverage to uninsured and uninsurable persons who were not eligible for Medicaid.

It has had its share of problems. It seems the legislature is now at odds with the officials who manage this program, resulting in "[poor] people being run over by the system."

This issues are symptomatic of healthcare being taken over by governmental officials, whose incentives are often not aligned with that of clinicians or patients. The 191,000 patients cut from the system as part of a "financial overhaul" does ring of a rather severe 'reform' that is likely not within the values of the healthcare professionals at the core of the program.

The legislators in this state fortunately seem to know that the program has stepped beyond certain bounds into the realm of patient abandonment.

Citing concerns about enrollees' rights, they do not OK rigid process for appeals

By ANITA WADHWANIStaff Writer

Lawmakers refused yesterday to approve rules that place strict limits on TennCare enrollees who appeal being cut from the program.

Instead, lawmakers on the Government Operations Committee told state officials they needed to provide more evidence about why these rules are necessary.

The lawmakers questioned the officials about whether the appeal rules violated enrollees' rights to prove they were being wrongly cut from TennCare.

"We're hearing stories about people being run over by the system. That's the thing we don't want to see and that's the thing I know you don't want to see," Rep. Beverly Marrero, D-Memphis, told the state officials. "Our concern is that people being dis-enrolled be given the benefit of the doubt."

New appeal rules have been in effect since the state began cutting about 191,000 people from TennCare this summer as part of Gov. Phil Bredesen's overhaul of the financially troubled health-insurance program for the poor.

State officials want the rules to be permanent and apply to anyone turned down for TennCare coverage in the future.

... Officials with TennCare and the Department of Human Services, which administers the appeal process, said the rules were fair.

A state official first determines whether an appeal presents a "valid factual dispute" before determining if it can advance to a hearing, said Lee Ann Bruce, an assistant DHS commissioner.

If state officials can see no facts in the appeal that would warrant a hearing, it is turned down, she said.

"If it's simply because you have a dispute with policies in place or can't afford" to pay for your own health care, "that's not a valid factual dispute," she said.

However, lawmakers remained skeptical of the process.

The time lines set by the state for people to provide documents showing they should remain on the program — from 10 days in certain instances — may not be enough time for people who are mentally ill or who have a debilitating illness, Marrero said. Rep. Mike Kernell, D-Memphis, was among lawmakers who recounted anecdotes of constituents turned down for hearings.

... Michele Johnson, an enrollee lawyer with the Tennessee Justice Center, told lawmakers that in about 40% of the hearings they had observed, people who qualified for TennCare were told that evidence they provided was "not relevant." Some were told to reapply, which can take up to three months.

Lawmakers at times appeared frustrated when state officials said they could not answer questions and referred them to other state officials who were not at the hearing.

At the start of the meeting, Harper asked why DHS officials, who had been specifically requested to answer questions about the appeal process, were not present.

"I'm going to dispatch someone to the governor's office," Harper said. "It appears they (DHS) are the ones who created the rules. They should be here to defend them."

DHS Commissioner Gina Lodge and Bruce hurried in to the meeting shortly afterward.

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